Original articleAt What Cost? Payment for Abortion Care by U.S. Women
Introduction
It is often assumed that individuals with health insurance can use it to pay for basic health care services. That is not the case with abortion care. Although 61% of abortion patients in 2008 had some type of health insurance coverage, 57% paid out of pocket for the procedure (Jones et al., 2010). Little is known about the reasons for this pattern.
The Hyde Amendment, first enacted in 1976, stipulates that federal Medicaid dollars cannot be used to pay for abortions except in cases where the pregnancy results from rape or incest, or endangers the woman's life. Seventeen states use their own funds to pay for abortion care for residents with Medicaid coverage, including several large states such as California, New York, and New Jersey. In turn, 20% of abortions in the United States were paid for by Medicaid in 2008 (Jones et al., 2010). Still, most women with Medicaid coverage would have to pay for abortions out of pocket. Moreover, even in the 17 states where Medicaid does cover abortion services, there are numerous barriers. For example, Illinois and Arizona are under court order to cover medically necessary abortions, but in practice almost no Medicaid abortions are funded in these states (Sonfield, Alrich, & Gold, 2008). In the remaining 15 states, barriers such as low reimbursement rates and delays in enrollment prevent some women and providers from using Medicaid for abortion services (Bessett et al., 2011; Dennis & Blanchard, 2013).
Only 12% of all U.S. abortions in 2008 were paid for by private health insurance and almost two thirds of abortion patients with this type of coverage did not use it (Jones et al., 2010). Two smaller studies found that the most common reason for this pattern is that women did not know if their plan covered abortion care services (Cockrill & Weitz, 2010; Van Bebber et al., 2006). This could be because many employers, including the federal and many state governments, as well as some religious and private employers, purposely exclude abortion coverage from their plans (Guttmacher Institute, 2013). Less commonly, concerns about confidentiality are another reason women forego paying with private health insurance (Cockrill & Weitz, 2010; Van Bebber et al., 2006).
In 2009, the average cost of first-trimester abortion was $470 (Jones & Kooistra, 2011), and most women obtaining abortions were poor or low income (Jones et al., 2010). These patterns suggest that abortion patients are confronted with substantial financial burdens to pay for these procedures. In 2008, 13% of abortion patients relied on financial assistance—in the form of discounts provided by the clinic or abortion fund subsidies—to pay for some or all of the cost of the abortion. Abortion funds are nonprofit organizations that collect private donations and work with abortion providers to help cover the cost of the procedure for women who otherwise could not afford it (Towey, Poggi, & Roth, 2005). That abortion patients are as likely to rely on financial assistance as on private insurance to pay for a termination suggests that these funds play an important role in financing abortion services.
How women pay for abortions may also influence at what stage in the pregnancy they are able to do so. Women seeking second trimester terminations face even greater financial obstacles as these procedures can cost two and three times more than those in the first trimester (Henshaw & Finer, 2003). Moreover, these patients cite travel and procedure costs among the most common reasons for delays in seeking care (Drey et al., 2006; Finer et al., 2006; Foster et al., 2008). Research has demonstrated that second-trimester abortion patients are more likely to use health insurance—both private and Medicaid—to pay for the procedure than first-trimester patients (Jones & Finer, 2012), suggesting that women able to use their health insurance to pay for the procedure are more likely to be able to afford the more expensive services.
The amount charged for abortion does not include indirect costs in the form of lost wages, childcare, and transportation. One study of 212 medical abortion patients found that women incurred indirect costs of $45 in addition to what they paid for the early abortion (Van Bebber et al., 2006). However, the sample was more educated than the larger population of abortion patients, obtaining their abortions before 9 weeks of pregnancy, and predominantly White; it is unclear whether lower income women would incur higher or lower ancillary costs. Some second trimester abortions require sequential visits to the facility over a 2- or 3-day period, and seven states require that women both receive their counseling 24 to 72 hours before the abortion and do so in person, necessitating multiple visits to the facility. These conditions can also increase the ancillary costs of abortion care.
Using data from women obtaining abortions across the United States, this study helps to fill in the gaps about how women pay for these services. Our analysis provides insights into why women with private health insurance do not use it to pay for abortion services and the role of financial assistance in subsidizing these costs. We also examine the ancillary expenses that many abortion patients incur (in the form of transportation, lost wages, etc.) and how women feel about requesting financial support.
Section snippets
Procedures
Data for this analysis were collected as part of a larger study of abortion care patients conducted between May and July 2011 at six abortion providers across the United States. We used purposive sampling, selecting facilities specifically based on their characteristics, in particular, their geographical diversity and wide range in gestational ages at which they provide abortion care. The facilities were located in major cities in Arkansas, California, Georgia, Illinois, New Jersey, and Texas.
Results
Most abortion care patients served on recruitment days were invited to participate in the study. The total participation rate was 86.1% for all clinics and ranged from 80.3% to 93.0%.
Discussion
This study confirms several patterns found in prior research and provides new insights into how women pay for abortion care. In line with abortion patients nationally (Jones et al., 2010), we found that the majority of women in our sample had some type of health insurance, but most still paid out of pocket for this service. Similarly, although women in the sample were about equally likely to have private insurance as to have Medicaid, they were more likely to use the latter to pay for the
Implications for Practice and Policy
In 2008, there were 1.21 million abortions, and it is estimated that 30% of U.S. women will have an abortion by age 45 (Jones & Kavanaugh, 2011). Despite the frequency of abortion and that many women will access services at least once in their lives, abortion care remains marginalized within the larger U.S. health care system (Harris, Cooper, Rasinski, Curlin, & Lyerly, 2011; Harris, Debbink, Martin, & Hassinger, 2011b; Joffe, 1995; O'Donnell, Weitz, & Freedman, 2011). Indeed, there are very
Acknowledgments
The authors thank Sandy Ma, Erica Sedlander, Jen Grand and Maya Newman, all of Advancing New Standard in Reproductive Health at the University of California, San Francisco, for assistance with data collection.
Rachel K. Jones, PhD, is a Senior Research Associate at the Guttmacher Institute.
References (22)
- et al.
Abortion patients' perceptions of abortion regulation
Womens Health Issues
(2010) - et al.
Timing of steps and reasons for delays in obtaining abortions in the United States
Contraception
(2006) - et al.
Predictors of delay in each step leading to an abortion
Contraception
(2008) - et al.
Dynamics of stigma in abortion work: findings from a pilot study of the Providers Share Workshop
Social Science & Medicine
(2011) - et al.
Who has second-trimester abortions in the United States?
Contraception
(2012) - et al.
Abortion stigma: A reconceptualization of constituents, causes, and consequences
Womens Health Issues
(2011) - et al.
Resistance and vulnerability to stigmatization in abortion work
Social Science & Medicine
(2011) - et al.
Patient costs for medication abortion: Results from a study of five clinical practices
Women's Health Issues
(2006) - et al.
Out of time and out of pocket: Experiences of women seeking state-subsidized insurance for abortion care in Massachusetts
Women's Health Issues
(2011) - et al.
Abortion providers' experiences with Medicaid abortion coverage policies: A qualitative multistate study
Health Services Research
(2013)
Risk factors associated with presenting for abortion in the second trimester
Obstetrics and Gynecology
Cited by (0)
Rachel K. Jones, PhD, is a Senior Research Associate at the Guttmacher Institute.
Ushma D. Upadhyay, PhD, MPH, is an Assistant Professor at Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco (UCSF).
Tracy A. Weitz, PhD, MPA, is an Associate Professor, in the Department of Obstetrics, Gynecology R.S. and the Director of Advancing New Standards in Reproductive Health (ANSIRH), both at University of California, San Francisco (UCSF).
This project was funded by the David and Lucile Packard Foundation.